A 64-year-old man was referred to our hospital for obstructive jaundice and acute cholangitis. He had severe motor and intellectual disabilities associated with cerebral palsy and required full assistance with activities of daily living due to right hemiplegia and limb contracture. Considering the risks associated with the prone position, endoscopic retrograde cholangiopancreatography (ERCP) was performed in the supine position. Cholangiography revealed stricture of the perihilar bile duct (Figure A) and double endoscopic nasobiliary drainage was performed (Figure B). A tissue biopsy from the stricture revealed adenocarcinoma, and the patient was diagnosed with hilar cholangiocarcinoma. His family did not desire surgical treatment as carrying a high risk for the patient and opted for palliative care. Thus, an uncovered expandable metallic stent was inserted (Figure C) and was placed using the stent-in-stent technique for tumor ingrowth (Figure D). The patient died 2 years later due to progression of cancer.
ERCP is traditionally performed in the prone position for ease of visualization and ampullar cannulation. The radiologic images taken during ERCP should clearly illustrate how the highly difficult procedure could be performed on a patient with severe motor and intellectual disabilities even in the supine position, thus serving as a point of reference for endoscopists.
Footnotes
Conflicts of Interest: The authors disclose no conflicts.
Funding: The authors report no funding.
Ethical Statement: The study was conducted in compliance with the Declaration of Helsinki and other relevant ethical guidelines and informed consent was obtained from the patient for publication of this report and any accompanying images. The study did not require institutional approval, as treatment policy was to be determined for single individual patients at the discretion of the attending physician.
Reporting Guidelines: CARE.